Lecture: Update on Macular Surgery

DR NAGPAL: Hello, everyone. It’s a pleasure to be here under the Cybersight banner. And good afternoon, good evening, good morning to you, wherever you are based, and today we’re talking about macular surgery. So just to brief you that, as the talk is going through, you can put in some questions, if you like, on the Q and A. And I will take them up at the end of the talk. And in between, there would be a couple of polling questions, which Lawrence would pop up, which you could choose, and we could just discuss the polling, based on that. And now let me just share the screen. Okay. So today we’ll be discussing macular surgeries. And I think over the talk, I will take you through just a brief about the diagnostics. And then the small incision surgery, and then go on to various macular surgeries, the most common being macular hole, then epiretinal membrane, subhyaloid hemorrhages, and so on and so forth. And I will take you through some surgical steps that we do for various presentations with each of them. Also a few complications that commonly occur in how we handle them. And then kind of look at the whole variety of situations that encompass the macular surgeries. So I think before you get on to surgery, just a few examples of how the diagnostics are today important with the OCTs, which help us determine the cause of various conditions in the macula. This is a classic VMT. What you see is a 3D representation of vitreomacular traction, and how it hampers the patient’s vision because of the pull on the macula. Here you can see the macular hole and how the hyaloid is involved with the macular hole and how the various stages come up and cause that. Vitreomacular transaction with ERM, which has come up — you can see both of these entities together here. And this is again a 3D rendition of how this looks like on the surface, on an OCT. So let me take you through the whole field of macular surgery. And you can fasten your seatbelts. And the small gauge surgeries have of course totally refined the way that we do all the surgeries. And of course, macular surgery is a big part of it. Typically I use 25-gauge in these situations. This is the incision that is left at the end of surgery. If at all you find any leaky wounds, you would suture them. In the past, when the small gauges came in, we did extensive work on how these incisions looked on anterior segment scans. And you can see we did this for 25-gauge, and you can see how the wound healing happens with these trocar cannula based 25-gauge incisions. It will still be fine with 27 and a little less with 23, but all three work quite effectively. And we published some of the data related to this. Lawrence, could you pop up the first poll? So I wanted to ask you as to — for macular surgery, do you have a choice? A 25, 23, or 27? We would just like to know what most people are using for macular surgery per se. Or you could distinguish for macular surgery — either way. Just choose whatever you use commonly at this juncture. 27 is a great gauge. The only problem is that I like to keep one gauge which works for all inventories. It’s good. But 27 is great for certain macular work. But you can see that 49% are 25-gauge, and the rest is divided with 23 and 27. That’s interesting. So let’s go to the surgical part. And as I always stress that macular surgery or any vitreous surgery is about the view. But macular surgery is much more about the view because you’re doing very fine work. You have to work at very fine interfaces. And my typical lenses that are used are contact wide field viewing. The Volk wide field is what I use for most of the surgery. And if I have a fine peel, I use the Volk plano lens, which works very well to give you a good magnification. So on a typical macular surgery, this is what I would start my surgery with. Wide field lens, which is put in so that I can get a better field of view. Where I would remove the vitreous, and after that, stain. The gross viewing is done with the wide field lens. Then I would switch to a plano lens, which is what gives you a very nice magnified view, a stereoscopic view, which allows you to peel quite effectively, without trying to have difficulties with the plane. When you pinch and peel, you want the plane identified very well. And here you can see the stereopsis, which is available to you, is excellent. So these two lenses are what I use, typically, for macular work. So when we talk of macular hole, which is the most common macular entity for surgical purposes, the most common step is PVD creation. So I use it with the wide field contact lens. And you can see the triamcinolone has stained and made these beautiful halos, which typically does for any attached hyaloid. And after that, using high suction, you pull it off, and then remove the residual vitreous and the triamcinolone. This is typically how I would do a PVD creation. The next important step is ILM peeling, which is done after staining with brilliant blue. In some places, people use ICG dye. We typically use a brilliant blue, which works very effectively in these cases. It hardly takes 20, 30 seconds for you to stain, and then you’re ready for it. This is the case of a traumatic hole. As you can see, there is a lot of disturbance around the edges of the hole, pigmentary changes, mottling, and it’s larger and not very well around it. So in this case, after a peel, this is an older surgery. I used to always use massaging to kind of release the contraction on the edges. So in the past, I would use the edge of the forceps or the cutter shaft to do this maneuver. And that would effectively seal the hole. You can see that this blood is from the trauma. The traumatic hole, which is located in the upper part of this — near here. But the central part is the hole related to the entity, and then you can close it with the massager. So now we’ve devised a massager which is basically a 25-gauge version of an external indenter. It’s as smooth a tip, a ball shaped small rounded edge, which works very atraumatically for this purpose. So I’ll show you an example. After peeling around the hole, we use this massager. Very gently — and it’s less traumatic than using something like a soft tip or a cutter shaft. Or the edges of a forceps. Which in the past I was using. And now this is what is most commonly used by us. And it works very effectively. Because there’s always a residual traction or a contraction on the edges. Even after you peel the ILM. And especially for larger holes, I think this maneuver works very well. And at the end of surgery, when I do air-fluid exchange, you can see that the hole is almost a pinpoint. So most of these holes tend to close during the surgery itself. By the end of it. So this is something we’ve published on the work of the massager. Now, this can be used for a different variety of cases. This is epiretinal membrane, along with macular hole. So this is a loosely adherent membrane. Sometimes the hyaloid itself is loosely attached. So we took it off with the cutter and stained it with triamcinolone earlier to check on the hyaloid which wasn’t there, and then finally stained it with brilliant blue, and now we’re peeling. So as I said, I always switch to the high mag lens, the plano lens, and you always get a great view of the central part. And this is something I feel one should not compromise. If you peel in wider field, you will get low magnification. And that may not be great for the viewing. So once again, the same steps that you peel and then gently apply the massager, and once you are sure that all 360 degrees you loosen the edges a bit, after that, you switch to air, and air-fluid exchange, and you will see that as the air-fluid exchange progresses, and you are aspirating over the hole, the hole almost becomes pinpoint. Which happens in most situations, as you can see here. Another situation where there is a partial tear, a detachment, and a macular hole — so detachments, at times, you might find it difficult to peel, and you could put perfluorocarbon. In this case, it’s there and it keeps the retina stable. And under that, you can peel the hole. With that also, I use a massager at times to again reduce the traction or the contraction on the edges, which is there. So after this, because there’s a detachment, you do the rest of the procedure. You endo-drain from the hole the tear which is there, and the posterior of the lattice. After that, you finish air-fluid exchange from the hole and finish with your laser and do the surgery. This is another case. Detachment with a peripheral tear. In this case, it peeled very well without the use of PFCL. I always start without PFCL, but if I feel that I’m not getting a good grasp because of the movement of the retina, I would put PFCL in these cases. One could always do PFCL to begin with, and use it when it is required. Here I’m putting PFCL after that, so I can push subretinal fluid to the periphery and it helps me stabilize the macular hole area, the retinal flat, and then you can endo-drain, flatten the periphery, do the laser, and the retina is flat. So these are macular holes coexisting with the retinal detachment with peripheral tears. But this is a case where there is a temporal giant tear, which is very posterior. And that is a macular hole also. And you can see that there’s a contraction, which has built up, because it’s so posterior. That between the hole and the tear, there is a contraction. And irregular folds. So our first thing is of course to do the hyaloid peeling. This is a post-traumatic situation. So you can see that there is a hyaloid — attached hyaloid admixed with some blood, which has hemorrhaged, engulfed by the vitreous. So the first step is to detach the retina, so you can take it away and make the retina freely mobile. So you can see that gently all that area loosens up, and gradually, we’re able to remove the whole vitreous along with that. After that, you can see that we are removing the ILM, the ragged edges of the hole are seen, we remove the ILM, and in this case, the ILM is removed up to the edge of the peripheral tear, actually. Because there’s so much contraction in the retina between the hole and the peripheral tear, that we feel that with the ILM extended temporally, that whole segment of retina would get relaxed. So here you can see that the ILM is being removed around the hole, and then we extend it to the periphery. As you can see here, I’m removing it from the peripheral part, extending that whole area, so that we get a little more surface area of retina temporally. There are also everted flaps, which we are ironing out gradually. And then of course under PFCL, you finish laser barrage. You save as much surface area as possible, because central vision could be there. And then do more laser to the other areas, except the temporal aspect. And at the end, of course, you do your air-fluid exchange from there. So this is a case where I’ll show you a few complications. Where, when you do a PVD induction, you have to always look for — especially the inferior periphery. Where you may have sometimes holes or tears created. And this is one such case. You can see that as soon as I finish PVD creation and I look below, I saw a little hemorrhage and a tear which had come up. Now, you go and clear up the vitreous from there. Then come back and do your surgery as if nothing happened. You finish your peeling, all that you would do normally for a macular hole. After making sure that you cleared the vitreous from all that area. And also using the massager. To make the edges of the whole tear variable. You can see that the stiff round edges now become a little softer. And at the end, you go back to that area, after the air is out, and you make sure that the whole vitreous is gone from there and do a good laser barrage to that whole area. And this saves you from facing a retinal detachment postoperatively. You would never have checked that area. You would just have been looking at the posterior part, and the next day or a few days after, the patient comes back with inferior detachment. So always look out for inferior breaks in any case that you do PVD creation. This is a post-op closure of this particular case. This is another patient of a macular hole. Where we were doing PVD induction. You can see that the staining is done. And now after that, I’m gently pulling that whole area. And you can see that now in this supranasal area, there is a bit of an elevation, which has come up. Because the vitreous there is so adherent. In that particular area. So supranasally, there is a convex area, which has come up, which seems to have some sort of an elevation, and as the PVD induction happens, you can see that there is a small break, with a lot of fluid collection, which has come up in that area. So anyways, I cleared the vitreous, and then went back and did the regular — the peeling process. Which was done. Finished that. Did the air-fluid exchange. And then went back and looked at that area. And you can see that that area is demarcated by some sort of a whitish hue. Maybe because of the edema or something which came up. It was a bit surprising, this area. Because normally you see some small tears, which can come up. But in this case, there was this small elevated area, localized. So I went ahead and barraged that whole area. Just to be on the safer side. And the hole had closed well. And this is the post-op closure of that hole. One month after the surgery. And you can see in the follow-up, if you look at the areas with the arrows, it’s where I barraged. And now that area is totally flat. For whatever reason, that evaluated and is well sealed and the hole is closed. So always look for any peripheral issues which might come up. Because PVD induction is a bit of a pathologic process. You are actually removing something which is meant to be adherent to that area. And at times, it can create problems. Now, this is a case with vitreomacular traction with an early hole in a case of retinitis pigmentosa. And in case, there is an adherent membrane which comes up. In this case, I want to show you a peculiar phenomenon that happened. But initially, of course, we’re doing the PVD creation. We have stained the hyaloid, and are gradually clearing up the residual area. Now, keep watching the macula. Keep watching. I’m just aspirating the residual triamcinolone with low suction. And can you see suddenly what happens? Suddenly that hole tends to open up a bit. Just because of that suction. And this is something I’ve noticed in some cases that happen randomly. And one has to be careful. So it’s probably a very small roof to that hole, which was attached. And it has come up. And that’s what probably causes this phenomenon. So anyway… We’ll go ahead and peel off the ILM. And you can see that this particular retina is a bit boggy, because of that fluid. The way the interface reacted. But of course, at the end, we could aspirate all that fluid and the retina flattened and the hole became pinpoint at the end of surgery. But this is something that can happen. You can deroof a VMT-like situation or an early grade 1 hole, which can behave like that. Now, this is a patient — I wanted to show you an interesting phenomenon. There are times when the patient sleeps and starts to snore in some situations. Sorry. This is a different one. Yeah. Let me just take you through one slide. So this is a patient where we’re doing a macular hole process. And wanted to show you that the patient suddenly is sleeping and decides to get up. And doesn’t know what happened and his head moves. And in this particular patient, something had happened, where the patient was sleeping. And at some point during the surgery, I was peeling. This is a time that you want to have very good magnification and stability. That the patient doesn’t move their head at such a point of time. Suddenly you can see that my whole view has gone. This is because the patient moved. And when I look back in, you can see that there is a break or tear, which has formed inferior to the disc. And so I went and aspirated the hemorrhage from there. Made sure it didn’t increase. Then lasered that particular area at the end. And luckily nothing else happened. But this is something one has to be careful with. Sometimes you’re happy that the patient is sleeping, and is not bothered, but a sleeping patient can be a disaster, if he just decides to get up at some point. Another similar patient is a snoring patient. Is again extremely difficult to manage for a peel. A snoring patient is okay for the broader maneuvers. But you can see how difficult it gets. You want to pinch, and the patient is snoring, and the whole head moves. I just wanted to show this to you. That this is a practical issue. Either you have to make sure the patient wakes up for that period, or you have to develop a technique where you move your forceps along with the snoring of the patient which is there. And here once again, as you can see, the patient gets up suddenly. I keep both the palms rested on the forehead, so I don’t create huge breaks when the patient suddenly moves. But you can see that there’s still a small area which my forceps touched, temporal to the fovea in this case also. So these can be practical issues which you might face, when you do these surgeries. It’s something that I face once in a while. And one has to be cautious. Always make sure if there’s a patient who is sleeping or snoring, try to wake him up while you’re doing this peel, so that he’s aware that he should not move his head during this period. So in fact, Lawrence, can you put up the next polling question? Before I go to the macular hole one? Okay. So I personally don’t do a lot of stuffing of ILM or anything. I believe in just peeling it and doing the massaging. But I just wanted to know: For large macular holes, which of the following techniques do you prefer, in relation to ILM peel? Is it ILM peel only? Or do you do stuffing of ILM in the hole or similar maneuvers, where something else is used to do part of the procedure? Okay. So a lot of people are using it to stuff at the end of surgery or similar maneuvers along with peeling. Okay. So a couple of cases of myopic macular holes that we look at. This is a high myopic patient, as you see. Who has come up with a hole and fluid around it. He had a detachment earlier which was operated, and he came back with a redetachment and a macular hole. So in these cases, you have to always explore sheets of ILM or a thick hyaloid sometimes can be there. You should put triamcinolone also to check. ILM tends to be thicker at times in these cases. In this, I got a sheet earlier. But I suspected there is more ILM there than what I saw. Maybe that is a hyaloidal sheet. So you double stain at times to double check that there’s no ILM left around the hole. And after that, the retina will get more malleable and will flatten more. This is a patient who was vitrectomized earlier. Was stable and at some point had detached again with a macular hole. This is another case with macular hole with posterior fluid. So you remove the vitreous. Sometimes you have this degenerative vitreous component, which is there in high myopics. You clear that up, and after that, you stain — look for any attached hyaloid, or any residual attached vitreous, which is there in high myopic cases. And after that, you go and do an air-fluid exchange. Now, there is a posterior port fluid here. In this case, I make a separate retinotomy away from the central hole to aspirate. So I don’t have to go and aspirate around the fovea itself. You can see the whole reflex of the macula changes and you’re away from the fovea when you do it. You can just do a mild laser to that point, while the macular flattens well in these situations. So this is something I use for myopic holes, where I don’t drain over the hole, at times. And then I put oil in this case. Lawrence, could you put the third poll question? So for myopic holes, do you do only ILM peel, ILM peel with stuffing, which we discussed, or do you do an autograft with retinal tissue or placenta or something else other than ILM? Which a lot of people are doing now for these cases. Okay. So I think it’s a lot of stuff equally divided. Some people do only peel, some people are stuffing it, some people are also doing autograft. As you can see, there’s no consensus on these things, and that’s why there’s a variety of things available to manage these situations. But let’s go to just epiretinal membrane at this stage. And you can see here a classic membrane, which is there. Once again, your first step is to do hyaloid peeling. You stain and remove it. After that, switch to a high mag lens, so you get a very good view of what you’re peeling. You remove the epiretinal membrane, which is seen very well. With this view, you can see the whole expanse of the membrane, which comes up. There’s always a tangential peel, that is — if you put it anteriorly, you don’t realize how much is the traction or the adherence, and you can sometimes get a break. So it’s always wise to do tangentially. And then of course, stain with brilliant blue. And you can peel the ILM. At times, some of the ILM would have been peeled already by the ERM. You may see gaps in the staining. While in some cases, you may have a full ILM which is left. So this is the ILM being peeled at the end of that. So very similar to what you do with macular holes, except that there’s no hole in these cases. This is another situation that has a much more adherent pathologic adherence that you can see here. Of a thick membrane. Most likely inflammatory nature of some sort would have caused a second remembrane in this case. So you can see that we first remove the vitreous, we’ve gone closer, switch to the lens of high mag. Now you can see how the whole interface attachment is there, and you can peel off looking very closely at all the structures below. So you know how much to pull. And if it is too adherent, then you would rather segment the cutter and leave the stump. But if it is peeling gradually, you go on peeling. And here you can see because of the adherence, there is superficial bleeding vessels which are there. But you can gradually peel off that whole area in the manner… So keep a visualization of that area perfect. So you don’t miss… The whole area where your forceps is moving should be visible to you in a good magnified manner. That’s the key to not create any breaks. And after that, of course, stain the ILM and remove that… Whatever is remaining of the ILM in this situation. This is another case of previous toxoplasma infection case. Which came to us with this kind of a fundus picture. With a membrane which had grown up over the macula, extending from the scar of the whole toxo lesion. And this is again — we expected a more adherent membrane than this. So first of all, staining, after that, use a high mag lens, so you can see the interface properly. And here we’re trying to find the edge, so that we can find a good cleavage to start off. And you can see that… The best place, if you don’t see the edge, is the macula. That’s the area where, even though it’s a crucial area, it’s the safest area, because that’s the depressed area over which there is a membrane. So whatever you pinch right on the fovea will always be the membrane. And not the retina. So actually, it’s the safest area. And here you can see that we thought that there would be a lot of adherence in this whitish area. But that part was actually very superficially adherent. For some reason, came off very easily. From that area. We were earlier not sure how that would behave. Or if a break could be created. But it’s a thick membrane, which was covering that particular area. And after that, we also removed the ILM, because there is extensive contraction caused by this thick membrane, which would be released better if you also release the ILM from that area. And this you can see is the post-op picture of the case. Flattened very well. Patient in fact got back 6/6 vision in this situation. In fact, had some recurrence of inflammation in the vitreous, which cleared off with some steroids. And the patient retained 6/6 vision in this case. Here we didn’t expect such a recovery, because of the thickness and the contraction which was apparent on the fovea. But the patient did recover quite well over a period of time. This is a case of a simple ERM preoperative picture I’m showing you. And I’m showing you a situation where the next time when I went in, and the patient — I went in and put my wide field lens and looked inside, this was the picture. So this was inadvertently a globe perforation, which happened while giving the block to this patient, outside. And as soon as I looked inside, I had to reconfirm that — what case is this? This was just an ERM. And this is what it looked like. So gradually, as soon as I came back to my senses, I start exploring, clearing up whatever I could see. And you can see this dense, dark blotch, subretinal, inferiorly — luckily what was around the macula seemed a bit superficial, except for the part — the second entry, which was seen near the fovea. And then of course the membrane for which we were operating was there. I went ahead and cleared it off. Which was… As planned, we removed that whole area of the membrane. And after that, this is the second entry, which you can see here. Which we lasered. And the main entry is more peripheral inferiorly. Fortunately the patient did well again. And this was his postoperative pictures in this situation. But this is something just to keep in mind. That once in a while, you can get a surprise there. This is a patient of a subsilicone macular pucker. You operate for a detachment, put oil, and after a month, comes back to you with this pucker. You still want to retain the oil in. So you just go back, and under the oil, peel the membrane. And don’t disturb the oil. Because you wanted it there for two or three months, so that redetachments or the retinal issue for which you put the oil is stable. So here you can see under oil, without disturbing it, what we do is put an infusion cannula, but leave it under air. So no fluid comes in to create emulsification of oil or increase the emulsification. You just put air so if the pressure goes down at any point, the air can compensate. And at the end, you can top up with more oil, which can be retained. So this is a post-op picture of the same patient. You can still see some holes, because this is just the next day. And over a period of time, those holes resolve. This is a case of a young girl with a hole. We had extensively lasered. Every time she would come with a new lesion in the periphery. We would keep lasering. And at some point, she developed a macular traction, which caused a small pseudohole, almost like a hole with traction, which can come up. That’s when we operated. You can also see some vessels, which are a part of that whole traction in this case. So here we went in, and Diatomized that vessel before cutting. Because it was kind of leading up to the traction, which was going towards the macula. And then of course gradually removed that membrane. We were anticipating that some parts would bleed. And so we keep the pressure high when you’re doing this. To make sure there’s no bleed. Or if the bleed is there, it doesn’t increase suddenly, and it can be contained in time. Yeah. So then of course, after removing the traction on the surface, we removed the ILM also. And once again, the patient did quite well in this situation. This is a macular pucker in the case of detachment. You can see this, which has formed on the macula itself. In this case, all you have to do is go back and remove it before you do the rest of the procedure. And then of course, in this case, it’s a good idea to also remove the ILM. So that you can relieve the traction fully in this situation. And then take care of the detachment. Vitreomacular traction is another entity that has to be carefully looked at. Because unlike a pucker or a hole where you can just go in and pull off the hyaloid, here you have to be careful. Because you don’t want to deal with — because the traction is pathologic and is pinpoint, and if you pull on the hyaloid, at times you may deroof that area. So here you can see that I gradually keep on removing the hyaloid. And decreasing — segmenting it from the periphery. And leaving only a sheath of — a small attached hyaloid. Now the high mag lens you can see clearly how this sheath of tissue is behaving. It’s like a small patch of hyaloid which is left behind. Instead of pulling it, I’m just keeping it to the last minute, so I can check that I don’t deroof it. And at the end, you can see that I’m peeling off the ILM. With the ILM, it comes off easily and in a much more controlled manner. So when you deal with VMT, you cannot just pull off the hyaloid, unlike what you did with the previous situations. And that’s where vitreomacular traction differs from these other entities. I’m going to show you a case where a deroofing-like phenomenon happens. This is a case of a more pathologic VMT. Much more circumferential traction. And you can see there’s already a fluid pocket with the hyaloid attached very densely. Over the macular area. So I gradually go closer and closer to it. By segmenting it from the periphery, before I approach it. And then of course, just to confirm how the traction is at this stage, put triamcinolone. But of course that has gone away. Here once again, as soon as I’m aspirating triamcinolone, you see how the hole just tended to open up, because of the connection of the fluid within. And the same way as I showed you the RP patient earlier, that had happened. So VMT can be tricky. Because there’s always a pathologic traction, and you never know which case behaves like one. Now, just a quick one for diabetic cases. And I don’t want to get into the details. You could have traction with diabetic cases for which you operate. Or you could do it for a chronic macular edema, which is not responding. Or you feel that constantly requires injections. So these are typical patients with chronic cystoid edemas. You can see with the high mag lens that the cystoid spaces are almost visible clinically. And here you go in and carefully remove the stained ILM from that area. But you have to be very careful over the thin macula here. And you should do this maneuver carefully. Because once again, with thin maculas, you could deroof these areas. Here I could see a good sheet of tissue, and I removed it without bothering about the fovea. And at the end of these cases, I usually inject an Ozurdex, because that helps remove the edema at the end of the ILM in these cases. This is another case which has a thick sheet of hyaloid, as you can see, which is visible. So this is again a chronic fibrosis situation, with a diabetic, where the edema keeps coming back, and there’s a thick sheet of hyaloid. So we first cut off the whole sheet of hyaloid. Again in the high mag lens. And you can see a very thin cystoid macula underneath. So in this case, I would do a fovea sparing ILM peel. I’m not trying to peel over the foveal area. I will peel from all sides and then leave a small stump around the fovea. So that I don’t end up trying to deroof that area. Because it’s already thin. And the last thing you need is to create a break there in that situation. Optic nerve pit is one situation where, again, we don’t have consensus on what to do. I think the basic step is to go and remove the hyaloid and put in gas. That’s the basic — now, with that, you could either do a bit of laser along, you can do an ILM people along, a lot of people stuff ILMs into this area. You’re seeing that I’m just creating a PVD, and you see the whole wave of PVD extending as I peel. So I personally believe in being a bit minimalistic here. Remove the hyaloid at times. If it’s chronic, I would do a little bit of laser on the temporal edge of the disc margin at times. But otherwise just do a basic hyaloid removal. In these cases, the key is to determine which cases to operate. Only those which have recent sudden acute loss of vision are ones which improve. But if you have a patient who’s got a chronic visual loss, these cases — they will not necessarily improve. A couple of cases of subhyaloid hemorrhages. This is a case of a diabetic patient. And here you can see that non-clearing subhyaloid hemorrhage is a great indication for surgery. It works very well. You clear that off, and suddenly the patient from almost no vision or centrally lost vision gets back good vision. But the key is to identify the hyaloid and remove it. Fortunately all the subhyaloid blood is usually always liquefied and is aspirable quite easily once you have the right plane in this case. Now, this is a sub-ILM hemorrhage. Which has partially dehemoglobinized. And you can see that we have stained the ILM. And I’m removing the sheath. The ILM on its undersurface has a lot of granular deposits of the remnants of the hemoglobinized blood, which is there. Underlying that. And once you have created this opening, you can gradually go and aspirate it with a cutter or any other instrument of your choice. And gradually that whole area will clear up. Again, these patients do quite well, because they don’t have an inherent pathology on the macula. It’s just that the blood lying over it causes the whole situation to be a problem. A couple of cases of subretinal bleed. A lot of people will use gas, and TPAs, and other things. For me, these medium-sized — large-sized ones also I operate and make retinotomies. I’m not showing it. It’s beyond the scope of this talk. But for medium and smaller sizes, I do positioning gas and anti-VEGFs. But for the thick hemorrhages, I like to make a localized retinectomy and remove that hole. So as you can see, I’ve made a very small opening prior to the vessel. And I reduce my cut rate to only 100 cuts per minute. So you imagine a 7,000 or 10,000 cutter is being reduced to 100 cuts per minute. It works like a scissor, and you have very good control, instead of disrupting the retina. You can very controllably make a scissor-like cut, and once you have the opening, you engage the hemorrhage, as well as the membrane. There’s a whole thick partially calcific membrane which is there. So you go in and use your full vacuum on it, gradually engage it, and in a gentle rocking manner, get the whole complex of the membrane, as well as the admixed blood. Which otherwise is never going to clear up. This comes off of that smiley-shaped incision that you’ve made. The smiley-shaped incision adds more surface area too. And then when it comes out, you can pick it with your cutter. At the end, that whole complex is cleared. You can see that it’s… That whole thick area is gone. I just put perfluorocarbon to iron the area out, flatten the break, and then put in gas. This is what it looks like in the pre and the post. You can see just under the superior arcade, you can see the smiley-shaped incision. And you can see how the fovea looks like. It’s not as bad as you thought, preoperatively, or during surgery. As the blood has cleared, the whole complex has cleared, the fovea is much healthier, and there is visual gain in these cases. This is the postoperative one month picture of these cases. Again, a similar case. Which I showed you before. I’ve done the same kind of situation here as well. You can see I’m using the cutter at a low speed. So that I have better control. And I don’t cut unnecessary tissue there. And then of course aspirate that whole area, put in some perfluorocarbon, just to keep the fovea stabilized. And after that, go in and aspirate all the blood and the tissue underlying that area. And you can see the whole complex comes off with the forceps here. I used it just to remove that complex. And then again, laser it. And iron it out. So these are just some examples of an assortment of macular surgeries. I think that’s what we have time for, before taking up the questions. You can see more of such videos on my #instaretinarf Instagram account, or longer videos on the YouTube channel at times, which are there. And also on Cybersight, there’s a lot of surgical videos related to retina. I’ve been posting over a period of time, and there are many others as well. So I would stop sharing this, and look at the Q and A at this stage. And feel free to ask questions for the next ten minutes. 15 minutes. So that I can take up one at a time. And try to answer them. So the first question I see is: Which brand is manufacturing the macular hole massager? We got it done locally by an Indian company called Epsilon. It’s available — it’s called the RF Massager. And maybe I could connect you to them. I don’t have any financial interests in it. But we could connect you to that… To the Epsilon company. If there’s any problem, get in touch with me and I can help you with that. In which cases do you recommend ILM flap technique? Personally, I just do the ILM removal. I don’t put in flaps. I don’t stuff flaps. It’s not something that I have ever understood the whole logic behind. The larger holes also — I like to massage. But I don’t put flaps. The only time I might consider using a flap or retinal tissue is a very large traumatic hole, where there is absence of tissue. Or very longstanding bullous edema, which has led to a large hole. But I don’t think for regular large holes I would do a flap technique. I would just peel the ILM, make sure the edges are loose and free, by massaging if possible, and that works well in most situations. The next question is: If a perifoveal retinal break develops during ILM peeling, what should be done? Should the breaking lasered? Extend the ILM people to the break? Or leave as it is? Great question. So yeah. Once in a while, you could have a small break forming. It could be inadvertent. Like I told you, if the patient suddenly moves, you could form — or it could just form out of sheer visualization issue or something else. So yes, most of the time, it is within the circumference where you are peeling, and maybe it would be a part of that. If not, yes. Good idea to extend the ILM peel to that part of the break. I would not laser it. Because these extremely posterior breaks don’t require laser. They seal on their own. Unless it’s a large tear which has formed. I’m only presuming it’s a small pinpoint break. No need to laser. All you need to do is put in air or gas, which you would do for the macular hole anyway, and it would not cause a problem. The next is: In the inverted ILM flap technique, does the flap size correlate in any way with the success of the hole closure? Once again, I’m not somebody who does this technique. Not sure about the size. But what I’ve seen — a lot of people just stuff it inside. And some of them do these flower petal techniques, where they peel from four sides or five sides, and leave the flaps and the edges. But I’m not sure if the size correlation is there with this particular condition or not. What surgical modality is preferred in optic disc pit maculopathy? So as I showed you with my video, there are so many ways of doing this. The basic step is to do vitreous removal, hyaloid removal. The basic part with gas is something which has always been there as a modality. And it does work in some cases. Now, in some cases, that may not have worked for various reasons. So you could do an ILM peeling, if the retina — if the macula is very thin on the OCT. Which you have assessed before surgery. There’s a lot of schisis. Then you would do an ILM peel without fovea sparing one. Because once again, these are cases where you can deroof it. And then you could add a bit of laser. Very light laser to the edges of the — the temporal edge of the disc. Which also sometimes prevents — so you could do a combination of these. But I don’t think I could give you a full answer to what is the best way. But various people prefer various things. Also some people remove the ILM and stuff it in the pit. Some people have used glues there. I go to the extent of removing hyaloid, fovea-sparing ILM peel, and a laser with gas. So if it has to work, it does work with this condition. And mind you, optic disc pit patients sometimes take up to 3 or 6 months to improve. So you may not see a dramatic change in a month’s time. Although it would have reduced. The fluid would have reduced from where you started. But it may not have flattened in a month. It may take two months, three months, up to six months at times. Can you tell us some view of double ILM insertion? Again, I don’t do the ILM insertion. If I’ve understood the question correctly, double ILM insertion… If it’s about inserting a flap, I’m not sure what a double insertion means. Do you almost always use triamcinolone for macular surgery? Yes. 100% of cases. That’s the one way to be absolutely sure that you don’t have any hyaloid stuck. Because I have had cases where I may have felt that oh, there is no hyaloid, I went ahead and did my peeling. At the end, when I did air-fluid exchange, I did see a thick sheet near the disc. Sometimes it’s nasally. You may not have hyaloid posteriorly. But you may have a nasal part from the disc. All that. They still have sheets of hyaloid. And it’s not a great idea to leave that sheet. In my surgery, I don’t recommend that you go all the way up to the periphery and do extensive peripheral trimming. But at least a gross hyaloid needs to be removed. Because that can lead to future breaks and other contractions. So yes. I would recommend always use triamcinolone. It gives you 100% confirmation that there is no hyaloid. That you’ve removed it fully. And it could be of great benefit for every surgery. Can we find more than one membrane of ILM? ILM is not known to have more than… If you’ve peeled from an area, there will be no second ILM. But as I said, sometimes we think it is ILM. And there is an ERM, which we have peeled. And we felt it was an ILM. So if it appears different than an ILM when you peel, you should always double stain. By double stain I mean — if second time, you feel what you peeled was the ILM, and you’re not sure, go back and stain again, and you may see remnants of the ILM. But sometimes the whole ILM is laying below and you removed a very thin membrane. So sometimes there are two membranes. Technically ILM cannot be more than one. ELM can sometimes be in sheets. Do you have any tips for beginners, just starting to learn ILM peeling? Which cases are ideal? How to initiate the peel? It seems to be the most difficult step. The first thing is good viewing. So I would totally insist that you are absolutely comfortable with the view before you undertake this process. Because whatever viewing system you use, whether it’s contact, non-contact, a good magnification is required to see the macula three-dimensionally. So that you can see the planes very well. And then you have two ways to do it. One is pinch and peel. Which… Maybe you may feel as a challenge to begin with… But eventually it becomes an easier technique. But the second way is to just use a Tanner scraper, or what we call the scraper which comes… A very gentle scraping is done, by which you can get a flap raised. And once you have a flap, it’s easy to start. Because once you’ve stained with brilliant blue, it’s easy to see the stained and unstained area very well. And the flap comes up quite well. So that is the best way, that you slightly scrape and you see a flap, and from there, once you have the edge, you can start and follow it from the stained or unstained area. Then it becomes easier. But once again, the view is the most important. If for any reason you don’t have a good view in that case, maybe the IOL is a problem, maybe there’s a posterior capsule issue, maybe the pupil is an issue, make sure that is sorted. Otherwise, it is better to leave ILM peeling and do the rest of the steps, rather than do an ILM peel with bad view and create breaks or bleeding and messing it up. So always have a great view before you go ahead with it. Your experience with ocriplasmin? I don’t have any experience. Now it’s not even available, I believe. But when we used to hear about it, it had 20% or 30% success in the best scenario. And we never got access to it. Because it was extremely expensive in India. Ocriplasmin never came in. It was even supposed to be quite expensive to be used for that time. So I don’t have personal experience. But today, as we speak, I don’t think it’s an option available for this particular condition. Surgery is the best way to remove a VMT or early macular hole. What is the preferred technique for recurrent macular hole in a young adult where the real primary etiology was trauma? Well, you first have to determine — with trauma, there can be a lot of tissue damage. And even with macular holes closing in trauma, sometimes visual recovery is not good. So first thing to assess is whether the patient has capability to improve. If you already operated once, and you feel you’ve done all the right things, of peeling and everything, then going in second time, you need to make a decision whether it will benefit or not. But if you feel there was something incomplete about the first one or you are not sure about the ILM peeling or it’s been operated elsewhere and you’re not sure, you go back in and do all the right things we discussed. And if at all, the peeling was incomplete — other things that may work, massaging may work, as I showed you. Or a lot of people use flaps and autografts. And you can try all that also. If you feel there’s a potential in that case, but there will be some cases where it will be futile, if it has been unsuccessful with a lot of pigmentary damage around the hole. How do you prevent ILM blue entering submacular space in myopic macular hole detachment? Is it wise to do ILM peeling under air in myopic? Well, I don’t think you need to do anything extra to prevent. Even if a little bit of dye goes… I don’t think it is harmful in any situation. But most of the time, even if you’ve seen some dye inside, and you finished your peeling, and when you do your air-fluid exchange, and you go back and aspirate over the hole, that dye would most of the time come out. So I don’t particularly try to do anything about it. I know that some people would put some PFCL — very small bubble of PFCL, just covering that much area, and then use the dye to stain. And after that, remove the PFCL bubble. So that’s something one could do. But I would not peel under air. The visibility is not great under air. Plus the air gives a lot of pressure on the retina. So when you peel, it is actually working against you. It’s probably not allowing the ILM to peel as easily. So the visibility is also much better under fluid. What’s the trick to do for ILM peeling? Again, I think what I discussed earlier. To have a good view. Viewing is the most important. And then you could use the finesse loop or the Tanner scraper. One of these instruments, to create a small flap and start from there. Any experience with long eyes and very fragile ILMs that easily break? Long eyes, again… There are some companies now which make longer instruments. You should try to get ahold of them. I think… I did acquire a few for myopic eyes only, because the regular ones sometimes are not… But if you don’t have access to them, you can take off the trocar, the cannula — it gives you another two to three millimeters of extra length, if you put the instrument straight into the port, instead of through a cannula. That’s one of the ways to get around it. What is the best viewing system in high myopic ILM? I use only contact. So I would totally swear by contact-based systems, whether it is myopic or non-myopic. Doesn’t matter. The view is excellent. I’ve seen a lot of my colleagues. We’ve seen non-contact systems also who get a very good view. So it’s about what you are comfortable with. What you have learned with. What you every day do, and are most comfortable establishing the view with. Do you perform ILM peeling in retinoschisis with visual loss? Well, if at all — retinoschisis, say an optic nerve pit with retinoschisis, but if it’s a recent loss, and not something which has been found on a routine examination and the patient already has an exotropic eye, I would not do it. But if it’s a recent loss, you’re sure about it, I would do it, but I would not peel over the fovea. Because these patients have very thin fovea, and you may create a break there. So yeah. In that situation… Is vitrectomy a better option than anti-VEGF for diabetic macula edema? No. I would think VEGF, you also have Ozurdex. These would reduce macula edema related to diabetic. I would only use vitrectomy if it’s extremely chronic, the patient is frustrated with injections, and you see large cystoid spaces not responding or coming back. And of course if you see any sort of membrane or traction, you could go in. But for a classic diabetic edema, I don’t think vitrectomy is better than anti-VEGF. Can you tell us again what lenses you use? Yes. I use the Volk contact lenses. I use the wide field SSV. SSV is the self-stabilizing lenses. So I use the wide field contact lenses by Volk. It comes in HRX — there is a model called HRX wide field. Which is used — which is very commonly used. There’s a plano lens, flat lens, or a plano lens, you call it. It’s like an irrigating lens. But without irrigation. And has flanges. It sits very well on the macula, which I use — when you want a very good high mag, that’s what you use at that stage. So these are the two lenses that I would use for all my surgeries. The wide field for all the surgeries, and the macular component of it I would switch to that. There’s also a Volk central lens, which gives you a very good view up to the equator. And gives you great depth. I use that for cases where I require a slightly wider view. But still don’t want an extremely wide view, and want good magnification. So it’s a balance between the flat lens and the extreme wide field. It gives you great depth for diabetic dissections. Because they extend arcade to arcade and are not located just on the macula. So the Volk has these two or three sets of contact lenses, which work fantastic for viewing and doing most of the procedures. Great. So I think that brings us to the end of the webinar. I thank you, all of you, for attending this. And sharing so many questions. And I hope it was useful. If you have any feedback to share to Cybersight with me, if you have any queries, which are still lingering, you could share your questions. And Lawrence would forward them to me. And I would be happy to be of any use. You’re also most welcome, as I said, to go to my Instagram, or #instaretinarf hashtag, or longer ones at YouTube. Thank you, Lawrence, for facilitating this.